The term “documentation” as used by SSA refers to the record SSA establishes and maintains
of its determination of an individual's benefit rights and the evidence supporting
that determination.

B. Policy

1. General

A documented record shows that the determination is in conformance with applicable
law. These instructions pertain to non-medical documentation. Medical documents will
be in various e-Dib files. For notifying the DDS about non-medical information, see
DI 11005.045

2. Documentation priority

Unless another POMS section specifically requires that a paper copy be kept, record
all non-medical evidentiary documents electronically using the following priority:

a. Initial claims:

•

MCS/MSSICS

•

EVID

•

Image (If available)

b. Title II PE situations:

•

EVID

•

Image (If available)

c. Title XVI PE situations:

•

EVID or Report of Contact (DROC)

•

Image (If available)

3. Standards for documentation

Documentation should reflect:

a.

Consideration for the claimant's due process rights;

b.

The opportunities provided to the claimant to submit evidence;

c.

A reasonable determination based upon the evidence in file;

d.

An adequate body of evidence;

e.

The electronic and paper versions of applications and other prescribed forms obtained
including:

Personal observations of the interviewer or other pertinent information (e.g., DROC,
RPOC or EVID per GN 00301.286A.4 where MCS or MSSICS cannot be used);

•

RPOC/DROC screens for Form SSA-553 (Special Determination) showing the adjudicator's
evaluation of conflicting evidence or complex issues and inferences made;

•

Prescribed questionnaires; and

•

Other material as appropriate;

f.

Whether the documented record constitutes “substantial evidence” to support the determination;
and

g.

Whether the documents in file are valid and authentic.

4. Improper documentation

Failure to document the claims file in accordance with evidentiary standards established
by SSA means the adjudicative decision is not properly supported by evidence and,
thus, may be erroneous, and result in payment errors.

Acceptance of documents of questionable validity or authenticity, and improper certification
of documents; and

•

Unexplained absence from the claims file of preferred evidence and reliance upon evidence
of lesser probative value.

C. Procedure — documentation requirements

1. General

Document the claims file so that it fully supports the adjudicative decision.

2. Establishing a fact

•

Refer to the POMS instructions pertinent to the issue involved.

•

Document accordingly. Unless expressly permitted by POMS instructions, subsequent
adjudicators/reviewers cannot make presumptions about information not documented in
the claims file. Facts not recorded in the claims file cannot be considered as evidence.

3. Guidelines not in POMS

•

A claims determination may be made based on a legal opinion pertaining to an individual
State law. When this is the case, document which legal opinion was involved. See GN 01010.830B. when the opinion was issued for the specific case being adjudicated. See GN 01010.810 when a precedent opinion is used to adjudicate the claim.

•

When a claims determination is based upon a regional instruction, follow the guidelines
in GN 00301.292.